Healthcare Provider Details

I. General information

NPI: 1306787684
Provider Name (Legal Business Name): FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE
NEW HAVEN CT
06513-3733
US

IV. Provider business mailing address

374 GRAND AVE GRAND PHARMACY 374
NEW HAVEN CT
06513-3733
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax:
Mailing address:
  • Phone: 203-777-7411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: BAIN PATRIE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 203-777-7411